The candidates’ health coverage proposals, ranging from Medicare-for-All to allowing the sale of insurance across states lines, vary dramatically depending on the candidate and the party. In advance of the upcoming debates, consider the following facts about the current state of health coverage in America.

Facts to Consider

Where do Americans get their coverage?

Today, just under half (46%) of Americans, or 152M, receive coverage through their employer. This percentage has declined over time, as enrollment in employer sponsored insurance has remained relatively flat, and government programs have expanded. Currently, Medicare and Medicaid enroll approximately 39% of all Americans, or 128M. Increasingly, both Medicaid and Medicare are administered by private plans, with 79% of Medicaid beneficiaries¹ in managed care and 36% of Medicare beneficiaries in Medicare Advantage.

Table 1: Current Sources of Coverage, In Millions, 2019²

Why is the number of uninsured Americans growing?

Following a decrease in uninsured in the immediate period following implementation of the ACA, recent data from the Census Bureau found that the number of uninsured individuals increased by approximately 2 million from 2017 to 2018. In addition to decreases in outreach and enrollment funding and improved Medicaid eligibility systems, a variety of factors are likely driving this increase, including high premiums in the individual market, increasing incomes that make fewer people eligible for Medicaid, and newly created jobs not including health insurance benefits.

Who are the remaining uninsured?

The remaining uninsured are predominantly low-income, especially prevalent in states that did not expand Medicaid. Today, Americans are more likely to be uninsured if they have not attained a high school diploma (29% are uninsured), are aged 19 to 25 (14.3% are uninsured), earn less than $25,000 a year (13.8% are uninsured), are Hispanic (17.8% are uninsured), are a foreign born non-citizen (28.6% are uninsured), and do not work full time (13.8% are uninsured).

How much are Americans spending on health insurance and healthcare?

Healthcare spending has been growing rapidly and is expected to continue to grow at an average of 5.5% from 2018 to 2027. Health insurance premiums are rising, with employer family premiums averaging $20,576 (of which the employee pays $6,015) and individual market premiums averaging $7,344. When combined with an average deductible, individual market premiums and cost sharing can reach nearly 23% of income for someone making $50,000 a year. These increases in patient costs are creating affordability challenges and are likely to continue to fuel a focus on healthcare spending and prices as a top political issue in the coming years.

How would reform proposals impact the current coverage landscape?

Importantly, the number of Americans impacted by healthcare reform proposals is largely driven by the eligibility parameters for any new coverage expansions. For example, reforms that implicate the employer sponsored insurance market are likely to impact a substantial portion of Americans, many of whom are uncertain about substantial changes to their current coverage. Smaller reforms, like introducing a public option in the health insurance exchanges or policies specifically targeting the uninsured, are likely to impact far fewer Americans.

How does the election shape what’s next?

Drug pricing debates continue in Congress, with competing proposals and legislative text in the House and Senate. In addition to continuing that discussion, a democratic candidate winning the presidency in 2020 is likely to shift focus toward expanding public programs and reducing the uninsured, while a re-election of President Trump will likely continue the administration’s efforts to replace or reform the ACA, while increasing flexibilities for health insurers.

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References

1. Non-dual beneficiaries.

2. Avalere Proprietary All-Payer Enrollment Model based on publicly available sources and projections of health insurance coverage.